MAINPRO-C and PBSG
Learning Programs
This newsletter
describes some of the important educational concepts and ideas underlying
the PBSG program and describes how these concepts can be used to evaluate
individual PBSG sessions. It will define those aspects of the program
that have made it eligible for MAINPRO-C credits and provide some specific
examples (case histories) to illustrate how the concepts can be applied
to real life situations.
The PBSG
practice based, peer facilitated approach to CME is a significant change
from the more traditional information based, and expert led, CME to which
we have all become so accustomed. The PBSG approach incorporates a number
of educational concepts and procedures that are significantly different
from those used in traditional CME and we think these differences are
rational, important, and make a valuable contribution to family physician
self directed learning. However, the differences are not always self evident,
nor do they always appear to be rational when they are evident.
Trying to
think about things in a way that is different from what we have been traditionally
taught is often difficult, time consuming, and frustrating. Old habits
and beliefs often prove hard to change, even for those trying to make
the changes. Some of the difficulty, initially at least, is related to
the lack of a shared understanding of the new concepts, perhaps even the
lack of a common vocabulary to describe them, amongst the planners themselves,
and amongst those the planners are trying to serve. I think those of us
who have been trying to further develop the theory and practice of the
PBSG approach are making progress in constructing new concepts, but we
have been remiss in not sharing the rationale for our activities, nor
the insights we have gained as a result of them, with you. We intend to
correct this oversight and this newsletter is the first step in that process.
Two Important Definitions
Problem
Based Learning (pbl) is essentially contextual
learning. Pbl sets out the learning tasks so that as much of the information
related to solving a given problem is provided within the context in which
it will appear in clinical practice. The theory behind pbl is that information
is stored and recalled in Achunks©of related pieces of information
rather than in the traditional biomedical disciplines such as anatomy,
pathology, physiology, etc. with the hope that the student will be able
to find the necessary information when it is needed1.
Practice
Based Learning (PBL) is pbl that carries the concept further to include
in those Achunks© of information the important issues related to
the practice venue (eg, limitations of time and space), and those related
to trying to apply general scientific knowledge to specific patient problems
which poses a major challenge for practising physicians2. PBL
seeks to provide opportunities for learners to consider scientific information
within the context of the practice in which it is intended for use, where
the limitations of time, and the complexity of the problem, may influence
decision making more than the scientific information itself.
PBSG groups
are self directed learning groups of self selected family physicians.
The primary objective of these groups is to help group members, collectively
and individually, maintain and enhance their professional competency over
a lifetime of practice. The PBSG program has been awarded Mainpro-C credits
by the College of Family Physicians of Canada(CFPC), because it meets
the criteria for this level of accreditation. The specific criteria that
guide the development and application of our learning materials and their
use are as follows:
- participants
are actively engaged in the learning process
- the learning
agenda and process are controlled by the participating physicians
- learning
is practice linked
- information
is critically appraised and trustworthy
- learning
is experiential as well as intellectual
- participants
can reflect back on previous discussions after having tried new ideas
in their practices
- self evaluation
is built into the process
- educational
materials are created by family physicians
- planning
committees are composed of practising family physicians
- academic
family and specialist physicians provide scientific and educational
support to educational development activities on an as needed basis.
The CFPC
believes that these criteria meet the essential elements of practice-based
reflective learning which is at the centre of its Maintenance of Certification
program and it is on this basis that the PBSG program has been accredited
by the CFPC for MAINPRO-C credits. It should be emphasized that this accreditation
applies to the entire integrated program, not to individual groups meetings.
The number of MAINPRO-C credits that a member can claim is equivalent
to the number of hours that the group meets, provided that the meetings
are conducted according to the intent of the program, utilizing program
materials and methods.
The criteria
can be used as a guide to evaluate the education worth of group activities
including those not based on a specific PBSG module. While this may appear
to be very straightforward, in practice it often is not and groups often
struggle with trying to evaluate sessions that are not based on educational
material produced by the PBSG program. The following suggestions are offered
for guidance:
The Use of Articles
Someone brings
an article which the group discusses for a complete session. If the article
was brought to answer a question that came out of a previous case based
discussion, and the discussion is focussed on that question and other
practice, and/or patient care issues, it is Mainpro-C. If the article
is brought because it is newsworthy and interesting, and the discussion
centres on the information contained in the article as it usually does
in a journal club, it is Mainpro- M1.
The Use of Specialists
The PBSG
program strongly encourages the use of specialists as resources when they
are used appropriately as a source of information to respond to specific
issues or questions that have come up in case discussions. Generally speaking,
local specialists are more effective as resources than those that come
from outside the community.
The essence
of PBL would occur if the specialist comes to address specific questions
which arose from a previous case based discussion, either from a PBSG
module or a case brought by a group member, and the discussion is confined
to those issues. It would not occur if s/he makes a free standing information
based presentation, or presides over a case based discussion, where the
problem is not a case that is clearly recognizable as a realistic problem
for the community in which the discussion is being held.
Briefing
the specialist on the needs and expectations of the group for his/her
visit is a crucial step in making the visit productive. If the specialist
is made aware of the clinical problem to be discussed and the unanswered
questions that the group would like addressed, the outcome is likely to
be more satisfactory to all concerned. Since the most common CME request
that specialists receive is to provide a lecture, it may be advisable
to explicitly point out to the specialist that the group is not requesting
a lecture on the question being addressed.
A good way
to maintain control of your educational agenda is to have a discussion
around clinical problems from your own practices first, and record your
unanswered questions. Relay those questions, preferably on a person to
person basis, to the specialist of your choice, and ask him/her to attend
your next session to discuss your clinical problems. Keep in mind that
the specialist is the expert on the biomedical aspects of the problem,
but, as family physicians, you are the experts on the practice aspects.
Be prepared to help your specialist colleague understand some of the realities
of community family medicine and work with him/her to devise solutions
to problems that don't conform to the typical medical school formulations
that are often applied to these problems.
Consultants
need not be invited to attend a full PBSG session. Most are quite willing
to attend for the period of time it takes to deal with the group's specific
questions3. Many groups report that the presence of guests,
especially those who are recognized experts in their field, have a dampening
effect on practice aspects of group discussion.
Other invited guests
Careful consideration
needs to be given to the implications of inviting guests who are not health
professionals. Patient confidentiality is always a prime consideration
in groups that are having practice based discussions and having guests
who are not health professionals creates the potential for breaching confidentiality
and/or inhibiting candid discussion within the group to avoid doing so.
Every time
you invite a guest to your group, you are potentially losing control of
your own educational agenda. This is particularly true when you invite
a guest who is sponsored by a third party. Educators all have their own
agendas and third parties choose educators whose agendas support their
own4. I am not suggesting that educators who are sponsored
by third parties are unethical. I am simply saying that they represent
a point of view that is likely to be in keeping with the party that sponsors
them, whether that sponsor be a professional organization or a pharmaceutical
firm.
The facilitator
should always continue to act as facilitator, even when guests are present
as s/he is the one who will be most in touch with the group's learning
needs, and therefore, best qualified to monitor group process and dynamics.
In the PBSG context, group meetings that are facilitated by someone other
than the group's own facilitator, or in his or her absence, another group
member, is by definition NOT a Mainpro-C activity.
Example of Third
Party Educational Modules
We have had
several queries from groups about the possibility of awarding Mainpro-C
credits to educational programs on depression that have been developed
and sponsored by various pharmaceutical firms. Because these materials
were developed outside the PBSG program, meetings held using them are
not considered part of the PBSG program and, hence, are not eligible for
MAINPRO-C credits.
From our
experience, the materials in these programs are usually scientifically
sound, but may not provide the appropriate contextual background. Consider
the following:
Much has
been made of the fact that clinical depression is Aunder-diagnosed©
and Aunder-treated© in family practice5. This assertion
itself is the offered rationale for development of educational programs
on depression for family physicians. While not denying there is room for
improvement in the diagnosis and management of depression in the primary
care setting, there is some evidence that the standard of care is already
quite high, and that the potential for improvement may be more related
to the reduction of organizational and practice barriers than to the increase
in physician knowledge6. The traditional educational programs
on depression for family physicians are poorly equipped to address issues
not related to the disease itself, because they are planned and executed
by content specialists who are not intimately familiar with the practice
problems confronting family physicians.
The presentation
and management of depression is different for specialists, than it is
for family physicians7. In family medicine, patients who are
depressed do not come having been previously labelled by someone else,
and do not come solely for an assessment of their depression. Depressed
patients are usually there because they have an unrelated problem such
as diabetes, hypertension, fatigue, insomnia, etc. and if they are to
be labelled, or even asked questions about their mental health, the physician
risks having the patient react negatively (so you think this is all in
my head, doctor!). And the time frame is different for specialists and
family physicians; it is ten minutes, not an hour, and the presenting
complaint must be addressed in that time frame as well. These differences
are not put forward as excuses for maintaining the status quo, but to
point out a need to address the practice based problems that form part
of the reality of family medicine. Strategies designed to manage the practice
problems of physicians, who must consider all of the health needs of patients
rather than a single need, and who must do so in a planned time frame
of ten minutes rather than an hour, will necessarily be different from
physicians who do not confront these problems. Strategies for these kinds
of issues can best be devised by those who are intimately familiar with
the family practice setting and the problems that are inherent to that
setting.
It is this
focus on the practice setting that generally distinguishes a PBSG module
from other pbl educational materials. The educational material developed
by industry are usually created by a group of specialists and the problems
included in the material are often more reflective of problems seen by
specialists than by family physicians. I am aware that planning committees
of these programs often include at least one family physician to provide
the family practice perspective, but one family physician in a group of
6 or 8 specialists can only be considered token representation at best.
In PBSG,
the problems, the information, and the clinical commentary, are all written
by family physicians to reflect problems that will highlight community
practice problems. They are all designed with the notion that the dissemination
of scientific information is the beginning of the educational program,
not the end. Learning how to apply that Ahard© data to the very Asoft©
world in which we practise is the real task to be addressed. PBSG problems
are designed to echo problems from the participants' practices and encourage
them to talk about their own clinical problems, not replace them with
Apaper problems©. That is why Mainpro -C criteria dictate that the
curriculum must be set by community physicians and the problems must be
defined by community physicians who understand the practice issues confronting
their colleagues.
References
1. Norman,
GR. Problem-solving skills, solving problems and problem-based learning.
Academic Medicine 1988;22:279-286
2. Hoey,
J. The one and only Mrs. Jones. CMAJ 1998;159:241-242.
3. Premi,
JN. Problem-Based Self-Directed Continuing Medical Education In a Group
of Practising Family Physicians. J Med Ed 1988;63:484-486.
4. Stelfox
HT, Chua G, O'Rourke K, Detsky, A. Conflict of Interest in the Debate
Over Calcium-Channel Antagonists. N Engl J Med 1998;338:101-106.
5. Agency
for Health Care Policy and Research clinical practice guideline: Depression
in Primary Care: Volume 1 Detection and Diagnosis 1993. U.S. Dept. of
Health and Human Services.
6. Williams
JW, Rost K, Dietrich AJ. Primary Care Physicians' Approach to Depressive
Disorders. Arch Fam Med 1999;8:58-67.
7. Schwenk
TL, Klinkman MS, Coyne JC. Depression in the family physician's office:
what the psychiatrist needs to know: the Michigan Depression Project.
J Clin Psychiatry 1998:59 Suppl 20:94-100.
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